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Month: December 2014

Over the past few years, I have reflected each New Year on the state of my profession and on life in general. Forgive me my hubris. I’m just old enough to think that I have something of value to say. This year I have struggled to not have this post sound like some sort of Jeremiah-like rant against the state of surgery and the profession’s abandonment of its own core principles. While I proudly claim the title of “Dinosaur”, facing one’s own extinction is hard, although obsolescence may be a better term than extinction.
First, the good. There has never been so much information available to the average surgeon. Through the Internet, multimedia presentations, online conferences and various university programs we have access to the latest research, evidence based protocols, and expert opinions in a quantity and quality unmatched in history. Critical examination and pooling of experience has improved our understanding of some very basic surgical diseases, replacing some of our most treasured (but erroneous) ideas about how to treat them.
Technology has continued to advance making new tools, treatments and techniques available at a breakneck pace.
The core of surgery, the commitment to technical excellence in the operating room, remains strong. I am gratified to see this strong commitment in my younger colleagues despite the changes in surgical residencies that have limited their experience and exposure to many clinical situations.
Personally, I am in better physical condition than I’ve been in years. I continue to be healthy enough to take Trauma Call, and although it takes me a bit longer to recover from nights without sleep, I can still hang in there with the younger surgeons. Age and cunning can give you an advantage over youth and enthusiasm.
I continue to write, both fiction and memoir. I have been honored to have met some very good authors and have the opportunity to talk to them as an equal about the craft and profession of writing.
My wife and I continue to have a strong and intimate partnership. She has nearly finished her Doctorate and together we can make a powerful force for change. She is a smart, passionate, and compassionate woman, and I am daily amazed that she picked me.
Our family has endured some stresses this year as all families do. But we have found the strength that resides in love and will persevere. We have two sons who have become good and kind young men and a grandson who is the new light of our lives.

Then there is the not so good. Change may be inevitable, but that doesn’t make it good. At this stage in my career I had anticipated coasting to the finish. Instead, changes in the way medicine is practiced and paid for have left me scrambling to maintain my practice and my prerogatives as an independent surgeon.
The big hospital systems continue their drive to consolidation, buying up facilities, building competing trauma systems that duplicate rather than complement each other and generally creating an environment that is hostile to the solo practitioner.
The same drive to monopolize the marketplace is leading to restrictions on our choices of specialists and facilities. Exclusivity in contracting can create synergy and simplify referrals, but only if the contractor is at least as good as the rest of the available specialists. Unfortunately, exclusivity tends to lead to mediocrity and we who depend on certain specialists for consultation are left with no alternatives.
Meanwhile, protocols and procedures continue to take precedence over thoughtful evaluations. Process has trumped outcome as a measure of our competence. We continue to spend thousands of man-hours and huge sums of money documenting compliance with protocols that have been demonstrated to be at best clinically irrelevant. All to ensure a continued flow of money from CMS. Many of my issues with the ACA and Medicare have little to do with reimbursements or insurance, and much to do with medicine by bureaucratic fiat. The agencies tasked with ensuring the quality of medical care no longer listen to those of us in the trenches who actually provide that care.
Some of my colleagues have surrendered to the creeping mediocrity of healthcare in the 21st century. Management by committee, healthcare by protocol, fragmentation of routine care to multiple specialists in the name of a care ‘team’, have replaced for them, the core concept of the surgeon as the captain of the ship. They limit themselves to the operating room and leave the rest of the patient’s care to the dubious skills of the Hospitalist. The have succumbed to the pressure to be little more than technicians and in doing so abandon the singular skill of the general surgeon – the ability to meld good medical care with surgical skill and take total responsibility for the care of the surgical patient.
I am not given to conspiracy theories, but the direction of healthcare in this new century seems to be on a steady course to eliminate the private, independent practitioner and replace him or her with a vague ‘team’ of healthcare managers. Decisions are to be made by consensus under the umbrella of standardized protocols and care delivered according to best practice guidelines. The thoughtful, sometimes inspired diagnosis will be a thing of the past, replaced by high tech imaging and computer diagnostic programs.
As I said, pretty much of a Jeremiad this year. Still, I will continue to do the best I can to preserve a way of life and practice that I was trained for. If you are a surgeon, it isn’t something you choose. You don’t look at a list of medical specialties and say, “I think I’ll give surgery a try”. You just know that this is the life for you; that there are few thrills or pleasures greater than the time you spend in the operating room perfecting your craft. The long hours, the missed holidays and events become burdensome at times, but in the end, the craft itself is the greatest reward. As Miyamoto Musashi says in The Book of Five Rings, “The Way is in training. Do nothing that is of no use.”

There’s an adage in surgery that change is bad; the only thing worse than change is change you don’t control. As with most such aphorisms, there is a hard core of truth about how surgeons view the world contained within it. We must deal with risk, both predictable and unpredictable, every working day. The tendency is to spend a lifetime doing things the same way because it is safe, it works for you and it reduces the unpredictable risks to a minimum.
Sometimes change is forced upon you, whether you planned for it or not. This is nothing remarkable. Everyone experiences unpredictable shocks, large and small, throughout their lives. Some of the biggest changes are sometimes the least predictable – the unexpected death of a loved one, the unanticipated loss of a job, the unwanted pregnancy, the discovery of a personal betrayal – are among the biggest life stresses that anyone will experience. And there is nothing unique about any of these things. We’ve all been there. And yet the personal experience of such a stress is unique, at least to the one experiencing it. It doesn’t lessen the emotional turmoil to reflect on the fact that many others have gone through the same sort of thing, or even worse things, and survived them.
Recently, the trauma center where I have worked for 23 years informed me that my services on the inpatient trauma team were no longer required. My contract to round on the trauma inpatients and provide ICU and ward care was canceled with a letter informing me that the hospital was invoking the 30 day notice off non-renewal built into the contract. Privately, the trauma director was quick to point out that this had nothing to do with my performance, but was a business decision. The hospital system that owns the trauma center is moving to an all-employee physician model and all of the independent contractors like me are being let go. I will still be doing three or four 24-hr trauma shifts in the ER each month ( that’s a different contract) but will no longer be involved in the inpatient care of the patients I admit to the trauma service.
I’ve tried to be objective about this and see it in a businesslike fashion, but it is still a personal blow. It’s like a veteran starting infielder being suddenly relegated to the role of pinch-hitter. I realize now that I have defined myself professionally for so long as a trauma surgeon that I am not sure what my identity will be going forward. My reaction isn’t unique. Millions of workers have had to deal with the loss of a job, often the loss of an entire career, because some manager decides they don’t fit the new business model being rolled out. In that, I am no different than many other middle level executives that have had to find new directions at a time in their lives when they expected to be coasting.
And, although I am not so naïve as to expect loyalty from an institution (that’s a rare enough quality to find in an individual), I realize that I expected something more than a form letter telling me of my demotion to second string. To be fair, the trauma director did make a very welcome personal effort to explain the move and reassure me that he still held me in high regard, but he doesn’t make the decisions about how the contracts are handled.
I still have my separate private surgical practice and can still be involved in the emergency care of trauma patients. The financial consequences of losing the contract will be significant but not crippling (I hope), and there are opportunities to expand my surgical practice now that a significant chunk of time is no longer committed to inpatient care. I hope to be able to take up the slack, but have no guarantee that increased availability will mean increased work. I won’t hurt for basic income even if it doesn’t.
Some other things will need to scale back, mainly commitments to free care. I will continue to set aside about a fifth of my volume as unpaid care and remain committed to the charities I already support, but medical mission work will not be practical for the time being. A planned West Africa trip was already canceled by the sponsoring organization due to the Ebola epidemic, but I’ve had to turn down a request from Canvasback Charities to accompany a surgical team to Majuro in March because I can’t afford four weeks off right now. And I’m debating whether to start looking for exit strategies a few years earlier than I had anticipated. I had always anticipated slowing down as I neared 65, but had figured it would be on my own schedule and not someone else’s.
Of course, I can always find another trauma center to take me on – they seem to be sprouting like weeds in the Phoenix metro area these days. Actually, that is pretty unlikely. Most of those centers are also looking for employees, not troublesome independent surgeons. And many are too far from my home to be practical in terms of response time (less than 30 minutes for back-up call). I could relocate, but don’t really want to start over again this late in my career. There are many options and I am ruling some out just because I don’t like them, not because they aren’t workable.
For now, I am doing nothing. I tell myself it’s because I’m waiting to see how the practice works out without the regular trauma work, that I’m ‘keeping my options open’. But I suspect there’s a big element of inertia and fear behind it. It’s not a feeling I am accustomed to. As they say, ‘A surgeon doesn’t have to be right, but he does have to be certain’. Right now, certainty isn’t in my repertoire.

I wasn’t always as conservative and risk averse as I am now. I blame my work. Anyone who can see the carnage caused by stupidity and risky behavior that I deal with on any trauma shift and still engage in high risk activities is either stupid or isn’t paying attention. But really, the process started before I became a trauma surgeon.
As a young man, I did a lot of risky things, beyond the usual drinking and driving and tempting fate that all 18 year olds do. I took canoes and kayaks down rapids that gave experts pause. I did free climbing in the Red River Gorge of Kentucky and in the Canadian Rockies. I engaged in the illegal sport of building climbing while an undergrad at the University of Illinois. Champagne-Urbana is a pretty flat place and climbing walls were a rarity. Our climbing wall was the bell tower of Altgeld Hall. Had we been caught, we’d have been arrested and likely expelled, but we weren’t.
By the time I started medical School, my risky behavior tapered off. I was too busy with studies and clinicals to do much. As a resident, sailing had become my favored passion and I spent my free time at the helm of a sailboat whenever I could.
So I wasn’t concerned when, as a new surgeon, I was assigned to a Marine Corps Surgical team. Part of our training was in rappelling. How they thought a bunch of surgeons and corpsmen needed that skill is beyond me, but I didn’t question it at the time. This was old hat to me.
We started on the 30-foot rappelling tower. I had done this so often, I could rig my harness in my sleep. I helped several other guys rig up and we followed the instructor’s lead and rappelled to the ground. I did it on a single jump, braking to a stop a few feet above the ground and stepping down as if stepping out of my car. Showing off, I know, but it felt good to be climbing again.
After the tower, they took us to Mangilao Cliff, a shear 150-foot basalt outcropping on the main Naval base on Guam. There was a road to the top, and one at the base, so it was perfect for training. I rigged up and confidently stepped off. After my second drop, I realized I was hyperventilating and my heart was racing. Halfway down, I was panting and my palms were sweaty. I was afraid. This had never happened to me on a rope before. I made it to the bottom and got control of myself. I felt weak and worthless, but hid it from the other team members, some of whom got stuck or wouldn’t even make the first drop.
I went home at the end of the day and told Michele of my fear and my feeling of weakness.
“Of course you were afraid, you idiot,” she said. “Unlike before, now you have something to live for.”
I realized she was right. My oldest son had been born just three months before. He would need me unlike anyone else ever had before.
Years later, as an assistant scoutmaster, I was able to teach my son and the boys in our troop some of my paddling and climbing skills. I still got a shiver of fear as I watched my 13-year-old firstborn make his first rappelling descent of Coon Bluff on the lower Salt River. His grin of accomplishment as he touched the ground was worth it.